Makulatranslokation – eine Therapie der neovaskuläre Makuladegeneration im Zeitalter der Anti-VEGF-Therapie?

 

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Zusammenfassung

Nachdem durch die VEGF-Inhibition eine signifikante Verbesserung für selektierte Patienten mit einer neovaskulären altersabhängigen Makuladegeneration (AMD) erreicht werden konnte, wird die Makulachirurgie – und hier unter anderem die Makulatranslokation (FMT: full macular translocation) – deutlich seltener für die neovaskuläre AMD angewendet. Dennoch kann diese Therapieoption in Einzelfällen sinnvoll sein. Eine prospektiv randomisierte Studie wies auf die Überlegenheit der Translokation gegenüber der photodynamischen Therapie (PDT) in Bezug auf eine möglichen Visusverbesserung hin. Weil trotz der operativen Komplikationen und der Störung des Binokularsehens viele Patienten mit Lesevisus und Lebensqualität deutlich von der FMT profitierten, sind Überlegungen gerechtfertigt, ob die aufwendige Operation in bestimmten Situationen eine sinnvolle Alternative darstellen kann. Hier muss berücksichtigt werden, dass den Zulassungsstudien von Anti-VEGF-Therapien eine Selektion vorausging, die im Vergleich zur täglichen Routine einen erheblichen Anteil der Patienten ausschloss. Deshalb können als mögliche Indikationen der FMT unter anderem Therapieversager der Anti-VEGF-Therapie, Patienten mit ausgedehnten submakulären Blutungen sowie Rupturen des Pigmentepithels gelten. Für die FMT sind aber wichtige Einschränkungen wie z. B. hohe Hyperopie, eine gute Funktion des Partnerauges und ausgedehnte Läsionen der choroidalen Neovaskularisation (CNV) zu beachten. Eine ausführliche Aufklärung möglicher Kandidaten über die relevanten Komplikationen ist eine selbstverständliche Vorbedingung.

Abstract

Since anti-VEGF treatment has been proven to achieve a significant improvement of visual acuity in a cohort of patients with neovascular age-related macular degeneration (AMD), macular surgery and particularly the macular translocation with 360° retinotomy (FMT: full macular translocation) have lost their former popularity. However, the approach of macular surgery still remains a promising therapy in selected cases. A prospective randomised study, comparing FMT and photodynamic therapy in subfoveal classic choroidal neovascularisation (CNV), recently showed the superiority of FMT in terms of visual gain. In spite of the postoperative complications and the disturbed binocular vision, the reading acuity and the life quality of many patients improved. Therefore, it is justified to discuss the chances and advantages of the FMT at least in selected cases. After all, case selection was an important determinant also in the phase III studies of ranibizumab; many patients seen during the routine consulting hours were excluded as a consequence of the study criteria. Most of them were suspected to achieve a less favourable outcome of the anti-VEGF regimen. Thus, patients who did not meet the inclusion criteria of recent studies or showed no response to the anti-VEGF therapy, as well as patients with extensive submacular bleeding or ruptures of the pigment epithelium can also be considered as candidates of FMT. Generally, in the presence of highly effective anti-VEGF drugs, FMT can be discussed for second-line treatment, if the fellow eye has poor function and no additional risk factors of the affected eye are known (e. g., hyperopia, large lesion size, etc). Detailed information relating to the potential adverse events have to be mentioned. Although the indication is restricted, surgeons should have the continuing ability to perform the challenging surgical procedure.

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PD Dr. Faik Gelisken

Department für Augenheilkunde, Eberhard-Karls-Universität Tübingen

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